SURGERY 2

o Arms over head

MODULE ON THE BREAST o Arms pressed against hips
Dr. Ong-Cunanan | Dr. Ngalob o Leaning forward

I. BREAST CANCER
 Risk factors
o Being a woman (100x more likely than in men)
o Age > 50
o Personal and/or family history of breast cancer
o BRCA 1 and 2 genetic mutations
o Hormonal Replacement Therapy use for more than 5 years

PRESENTATION OF BREAST CANCER

S/Sx Frequency (%)
Lump 76
Pain 5
Nipple retraction 4
 And inspect for skin changes, symmetry, contours, and retractions
Nipple discharge 2
Skin retraction/dimpling 1 Appearance of the Color, thickening of the skin
Axillary mass 1 skin
Size and symmetry Some difference in the size is common and
 Orange peel - due to blocked lymphatics
usually normal
 Nipple retraction – retraction of Cooper’s ligaments
 Supraclavicular nodes Contour of the Changes such as masses, dimpling, or
 Inflammation breasts flattening
 Ulcerations/fungating masses – signs of advanced breast cancer Characteristics of Size and shape, direction in which they point,
 Phyllodes – tear drop appearance the nipple any rashes or ulcerations, any discharge
*long-standing inversion is usually a normal
INCIDENCE BY LOCATION variant
 Most common site of
breast cancer: upper PALPATION
outer quadrant  Palpate the breasts, including augmented breasts
 Patient should be supine with the ipsilateral hand on her
forehead and her shoulder pressed against the bed. This
flattens the breast tissue
 Palpate the breast tissue against the chest wall using the finger
pads of the 2nd, 3rd, and 4th fingers, slightly flexed
PROGNOSIS
 Use a systematic approach:
 The size of a breast cancer and how far it has spread are important
o Vertical strip pattern: best technique
factors in predicting the prognosis
o Circular
 Diagnosed with breast cancer that spread to nearby lymph
o Wedge
nodes: 83% 5 year survival rate
 Make sure to palpate the area from the clavicle to the inframammary
 Spread to other parts of the body: 23% 5 year survival rate
fold and from the mid sternal line to the posterior axillary line and
the tail of the breast
THREE STEPS TO EARLY DETECTION
**Early detection is your best protection- if breast cancer is found
and treated early the five-year survival rate is 98%. The key to early
detection is screening

1. MAMMOGRAM
 The American Cancer Society and the American Medical Association
recommends annual mammography beginning 40 years old
 Detects unexpected breast cancer in asymptomatic women.
Supplements history taking and physical examination
 Two views are obtained: Craniocaudal (CC) and mediolateral oblique
(MLO)
o MLO view shows the greatest volume of breast tissue
 Most important indicators of breast cancer: Masses and
microcalcifications

2. CLINICAL BREAST EXAM (CBE)

TECHNIQUES OF EXAMINATION
 Done every 3 years for women 20-39 years old and annually after 40
years old
 Breasts tend to swell and become more nodular before menses
o Therefore, the best time to do CBE is 5 to 7 days after the onset  Palpate in small, concentric circles at each examination point,
of menstruation applying light, medium, and deep pressure
INSPECTION  Begin laterally then move medially (for the vertical strip technique)
 Patient is in a sitting position and disrobed to the waist  Make sure to include the axillary tail
 Inspect the breasts in 4 views:  Make sure there is at least 6 inches of space between you and the
o Arms at sides examining bed. Your groin should not touch the patient

Transcribers: JULIAN Page 1 of 2

 SURGERY 2
 Between 4 and 12 samples are acquired at different positions within
 Note for the mass
o Consistency, tenderness, and nodules  Tissue specimens are placed in formalin and processed to paraffin
 Note location, size, shape, consistency, blocks
delimitation (well-defined or ill-defined  https://www.youtube.com/watch?v=-PYKLe4R3tU
margins), tenderness, and mobility
Consistency  Normal consistency varies. Physiologic nodularity
may be present. Ribs may be mistaken as a hard
mass if pressure is too deep
Tenderness  As in premenstrual fullness, duct ectasia, etc..
Nodules  Location: by quadrant or clock + cms from the
nipple
 Size: in centimeters (cms)
 Shape: round/cystic, disclike, irregular
 Consistency: soft, firm, hard
 Tenderness: some cancers may be tender
 Mobility: in relation to the skin, pectoral fascia, and
chest wall. Watch for dimpling

***Hard, irregular, poorly circumscribed nodules, fixed

to the skin or underlying tissues strongly suggest cancer

 Palpate each nipple. Press more

firmly to check for discharge
 If you are male, you must have a
female companion during the
entire examination

**Breast examination (cramming? SKIP TO 6:00):

https://www.youtube.com/watch?v=tGiy5Y8Rdag

**for more details, please read Bates’ guide to physical examination and
history taking

3. SELF-BREAST EXAM
 Should be done monthly by the patient 6-7 days after the end of the
menstrual period
 Steps
o Visual
o Standing/sitting upright
o Lying down

BREAST BIOPSY
1. Fine needle aspiration biopsy
2. Core needle aspiration biopsy
3. Open biopsy
4. Frozen section

FINE NEEDLE ASPIRATION BIOPSY

 Allows for cytologic evaluation of specimens
 Makes use of a 1.5 inch, 22-gauge needle attached to a 10 mL
syringe
 After the needle is placed in the mass, suction is applied while the
needle is moved back and forth within the mass
 Once cellular material is seen at the hub, release suction and
withdraw the needle
 The cellular material is expressed onto microscope slides
 Both air-dried and 95% ethanol-fixed microscopic sections are
prepared for analysis
 FNAB techniques:
https://www.youtube.com/watch?v=mXh9en_nCBU
o SKIP TO 4:19-4:36; 8:22-9:54;
o FNA sampling procedure: 10:50-14:09

CORE NEEDLE ASPIRATION BIOPSY

 Allows analysis of breast tissue architecture and determination of
whether invasive cancer is present
 Makes use of a 14 gauge core needle biopsy needle (tru cut
needle)

Transcribers: JULIAN Page 2 of 2